Flashcards in Final Deck (63):
MOSTLY be NEW material, but some review material.
60-70 ?'s multiple choice, and 15 free response
Will be a video on gait analysis
You will have to analyze gait through a video on the final.
Ankle rocker – tibial advancement
DF and PF
Stance vs. swing phase
Knee flexion and extension
Should be close to extension at toe touch down, and
get to about 60 degrees knee flexion right before
No genu valgus/varus
Hip flexion (about 30 degrees) and extension (about
There should be some hip counter rotation
Arm swing should be reciprocal to the legs movement
Did a high guard where you abduct arms in fear of
BOS (base of support) should be normal.
Toe in / Toe out
LOOK at email Leandra sent out of all the videos
He'll ask us to identify a temporospatial and an angular pathology with gait
***** REFER to the Handout he gave in class on temporspatial, angular, event, and posture aspects we'll need to analyze
Below are flashcards on the ANKLE
1) What are the 3 regions the foot is divided into?
2) What bones compose those 3 regions
3) What are the 2 main functions of the foot:
4) What are the STABILITY functions of the foot
5) What are the MOBILITY functions of the foot
- Hindfoot: talus and calcaneus
- Midfoot: Navicular, cuboid, 3 cuneiform b's
- Forefoot: Metatarsals and digits/phalanges
3) Provides stability and mobility
- It is our BOS ... provides stability
- Stable lever during push off of gait (windless mechanism during terminal stance phase)
- Mobility: accommodate torsion between joints during close chain motions
- Allows shock absorption (knee and medial longitudinal arch especially)
- Mobile to conform to uneven surfaces (foot undergoes contour changes so foot can remain in contact with the ground during uneven surfaces).
1) Another name for the ankle joint. Why?
2) Primary purpose of Talocrural jt
3) Is dorsi or plantar flexion true extension of the foot
4) What is congruence (with regards to 2 bones)
- When is talocrural jt most congruent
5) What is closed pack position of talocrural jt
- What is lest packed position of talocrural jt
6) Which joint(s) probably have the most contact or congruency through its ROM
- Which jt has the MOST congruence?
7) T or F: The ankle has a low incidence of OA (osteoarthritis). Why?
- Is there OA in that joint?
8) How much weight can talocrural jt sustain
1) Talocrural jt (talo for talus, and crural are legs ... so malleoli are legs from tibia and fibula).
2) Allows dorsi and plantar flexion (hinge joint)
3) Plantar flexion = extension
4) When the 2 bony surfaces are most aligned (tight) in together
- Mid plantar flexion (between neutral and full plantar flexion)
6) Ankle, hip, shoulder
- Ankle is most since on every side it has congruence
7) True. Because it is very congruent, and in other joints you get point pressure (like condyles of knee)
- Yes, it can still get OA when it gets injured or fractured, then OA goes up.
8) 4-5x body weight
1) T or F: The proximal tibio-fibular jt is part of the ankle jt and ankle motion?
2) What is the function of the proximal tibio-fibular jt
3) Is the proximal tibio-fibular jt a diarthrodial or synarthrodial jt
- So what type of jt is it?
4) What are the motions of the proximal tibio-fibular jt
5) Does the proximal tibio-fibular jt. have a capsule and ligaments?
(Go through Shively's Anatomy book to help you compile that list of ALL joints in thy body, the type of joint each is, movement it allows, etc. etc.)
2) Allow rotation of the fibula with regards to the tibia, and upward glide motion of fibula during weight bearing.
- Remember the distal tibio-fibular jt needs to be solidly in place to hold the lateral malleolus (distal fibula) snug into the ankle joint to provide stability around the talus.
- Plane jt
4) Some rotation, and some superior/inferior glide.
5) Yes. There is an anterior and posterior capsule / lig holding head of fibula in place.
1) What is the lig between the tibia and fibula
2) What is the purpose of the interosseous membrane
3) Explain fiber orientation of the interosseous membrane, and why? Why?
1) Interosseous membrane
- Ties / holds the tibia to the fibula
- Muscles of ant and post compartment of the leg attach here
- Passes and SHARES stress between 2 bones (like in forearm)
3) One layer goes one direction, and the other runs perpendicular in opposite direction. So one goes on stretch while the other goes on slack during rotation / movement to help share forces.
1) What is the other jt associated with the ankle but not part of the talocrural jt
2) What is the purpose or function of this jt
- Does the distal tibio-fibular joint move
3) What % of body weight passes through the fibula and tibia?
- Can you do without either one of these bones?
- Why would you NOT want to get rid of that more unnecessary bone?
4) What type of jt is the distal tibio-fibular jt
- What does that mean?
5) A 'high ankle sprain' is what
6) How is the distal tibio-fibular jt similar and not similar to the SI jt.
7) So we know the distal tibio-fibular jt holds the tibia and fibula together, so does the proximal or distal tibio-fibular joint MOVE?
- So Axis or AOR for fibula is where?
8) Where would you palpate the distal tibio-fibular jt?
1) Distal tibio-fibular jt
2) Binds the distal tibia to the fibula, creating the ankle mortise or 'crura' / legs of ankle joint (between the malleoli) to surround and support the talus in place.
3) 10% through fibula, and 90% through tibia
- You obviously need the tibia, but yes, you technically could get rid of fibula and be fine.
- Keep in mind the fibula holds the talus in place. You lose the fibula, then the talus can freely move laterally (that's bad). Also, you'd thus lose the proximal tibio-fibular jt higher up which helps in shock absorption and bearing weight and motion at the ankle. So fibula is important :)
- A syndesmosis is a slightly movable fibrous joint in which bones such as the tibia and fibula are joined together by connective tissue. Examples include the distal tibia fibular joint as well as the radioulnar joint.
5) Injuries to the distal tibio-fibular jt / ankle syndesmosis are commonly known as a "high ankle sprain".
6) It is similar in that it has an anterior and posterior lig portion with an interosseous lig portion in between. But SI lig has a diarthrodial portion, and distal tibio-fibular jt does NOT have any diarthrodial element to the jt.
7) Proximal (higher) one is where the movement happens.
- AOR is at distal tibio-fibular jt, and the top/proximal portion moves, rotates, shears, etc.
8) Find lateral malleolus, and go just proximal to it. It would then be medial/internal to the bone between the fibula and tibia.
1) Explain the bony structure of the distal tibia
- What is the radiological name for that area
- Where roughly would you palpate to be near this area
2) Explain main bony landmarks of the talus
3) What is the name of the area at the top of the talus dome, bottom of or distal tibia, and between the two malleoli.
4) Is the talus dome/trochlea wedge shaped? Explain
- Why is this important to know?
5) The talus top portion is dome shaped, and it bends down to form what:
- Would the lateral or medial facet of the talus be larger? How do you know?
6) What is the difference between talar tilt and talor torsion
7) What is the sinus tarsi
- What does that term mean?
1) It is essentially flat, but there is a slight ridge where the middle portion is slightly peaked distally, and sides are thus oriented a bit more proximal/superiorly, to allow a groove during movement (dorsi/plantar flexion).
- Medial mallelous (just internal / deep in ankle joint)
- Base (distal) is the head, neck, and body (head is anterior).
- Projecting portion where ankle jt articulation happens is the trochlea, with the dome on top. Medial and lateral tubercles are more posterior.
3) Ankle mortise
4) Yes. It is wider more anterior.
- Because as you do dorsiflexion, that anterior wider wedge gets shoved between the two malleoli, thus why it is a closed packed position.
5) Two facets for the malleoli. The medial and lateral facets for the 2 malleoli.
- Lateral. Because the lateral malleolus descends further distally, thus needing larger area for that facet region.
6) Talor tilt is the dome rocking back and forth medially to lateral. Talor torsion is same as internal and external rotation.
7) The sinus tarsi is a tunnel between the talus and the calcaneus. The joint between the talus and calcaneus is also known as the subtalar joint.
- Sinus is hole, and tarsi refers to the talus ... so hole under the talus bone.
1) Explain the ankle jt capsule lig's.
- Are the ankle capsule lig's strong or weak?
2) What is the difference between capsular lig's and collateral lig's
- Are Collateral lig's intra or extra capsular?
3) Starting on the lateral side, how many collateral lig's are there on your lateral ankle
- What are they (name and explain them and what they do)
4) Most likely if you have a lateral ankle sprain, you sprained what ligament?
- Would that be an inversion or eversion sprain
- Where would you palpate this lig to see if it is torn
- What is it called if this lig is ruptured
5) What is the 2nd most commonly torn lateral collateral lig of the ankle?
- A bad ankle sprain, what 2 ligs would be torn
- So the Calcaneo-Fibular lig would be stretched if the calcaneus bone does an extreme valgus or varus motion?
6) Would spraining the Calcaneo-Fibular lig contribute to Anterolateral rotary instability
7) Which of the 3 lateral ligs of the ankle is NOT put on strain during inversion of calcaneus?
8) Which of the 3 lateral ligs of the ankle are easy to palpate, which are not? Why
9) Which of the 3 lateral ligs of the ankle is torn the least
10) Are the 3 lateral collateral ligs of the ankle part of the ankle jt. capsule?
1) Ant and post capsular lig.
- Weak (they are very thin)
2) Capsular are part of the capsule and protective covering (keep synovial membrane and fluid in). These are typically weaker. Collateral are outside capsule and much stronger.
- Collateral ligs are extracapsular.
- Anterior Talo-Fibular Lig (ATFL)
- It prevents too much varus at the ankle
- It prevents extreme plantar flexion
- It prevents extreme talor torsion medially
- Posterior Talo-Fibular
- Weakest of the 3, and doesn't often get injured
unless talus comes completely out of malleoli
- It prevents too much inversion (thus is stretched in
4) Anterior talo-fibular lig. (ATFL)
- Just above the sinus tarsi. Find dome of talus on lateral side and its between that and distal fibula's malleolus
- Anterolateral rotary instability
5) Calcaneo-fibular lig
- ATFL and Calcaneo-Fibular lig
7) Posterior talo-fibular lig.
8) Anterior talo-fibular and calcaneo-fibular are easy to palpate, but the posterior talo-fibular is hard to palpate. The posterior one is deep to Achilles tendon down in behind tendon/fat of posterior ankle area.
9) Posterior talo-fibular lig
10) No, but they apply to the outer portion of the capsule
1) What is the main big ligament on the medial side of the ankle
- Is this lig part of the capsule? Explain.
1A) Is the deltoid lig strong?
- Explain why it is so strong
2) What is the main purpose of the Deltoid lig ... what motion does it resist.
3) What are the named portions of the Deltoid Lig
4) Is the tibio-spring band same things as the spring ligament?
1) Deltoid lig
- Basically, yes. It is deeply imbeded into the capsule. It is 2 layers deep, and the deep layer is part of the capsule.
1A) VERY strong
- Typically you'll fracture the medial malleolus before you tear the deltoid lig.
- Resists valgus stress of ankle ... or lateral motion of the bottom of the calcaneus
- Prevents too much eversion
- Tibionavicular (band)
- Anterior tibio-talar (band)
- Tibiocalcaneal (band)
- Posterior tibio-talar (band)
- Tibio-spring (band)
4) NO. The tibio-spring band is a part of the deltoid lig that goes down and connects to the spring lig.
1) What type of joint is the ankle joint
2) Is the lateral or medial malleolus more distal (or inferior)?
- Which one is more anterior?
3) Where is the AOR for the ankle joint
- Explain what is unique about this AOR
4) Remember measuring for tibial torsion and how the malleoli are angled ... that is how/why the AOR for the ankle joint is technically not just the lateral malleoli
- Usually a normal tibial torsion angle is about how much
5) Because of this alignment of the malleoli and thus tibia orientation, explain how the foot moves during dorsi and plantar flexion
6) How much dorsiflexion do ppl usually have
- How much PF?
- How much DF and PF do you do during gait?
7) What checks dorsiflexion
8) What checks plantarflexion
9) What muscles go on stretch during PF
1) Hinge joint
- Medial malleolus
3) Technically we do it at the lateral malleolus
- But it is angled since the medial malleolus is more anterior, so it runs more at an angle between the two malleoli (through the upper dome of talus which is the convex member in that joint).
- 20 degrees
- Dorsi: foot moves up and laterally
- Plantar: foot moves down and medially
6) 10-12 degrees if knee extended (can get up to 20 with knee flexed)
- 40 ish degrees
- DF you do about 10-12, and PF about 20 degrees.
- Wedged shape of anterior portion of talus (talor dome) causes bony apposition. This is the main check. But also:
- Achilies tendon
- A little bit from posterior capsule and ligs
- ATFL goes on stretch (and calcaneo-fibular lig)
- Deltoid (part of it) goes on stretch
- A little from muscle tightness in anterior leg compartment
- Anterior compartment of the leg m's
1) What is talar tilt?
- About how many degrees is a normal talar tilt
- If there is a noticeable tilt showing up on a radiograph, what might that suggest is happening.
2) What is talar shift?
- Would talar shift be more or less in dorsiflexion? Why
- If there is a noticeable shift showing up on a radiograph, what might that suggest is happening
3) What is talar torsion
4) Is the medial or lateral facet on the talus larger?
- So which malleoli moves more. Why?
5) Most instable part of the ankle is the medial or lateral side?
- Thus, when people get an ankle sprain / break, typically it is on what side?
1) The talus does tilt medially / laterally.
- 5 degrees
- A torn ligament
2) Where talus shifts back and forth between the two malleoli (not tilt) just shifts medial to lateral.
- LESS (non-existant). Because it is closed packed position and talus can't shift as it gets wedged in more between the two malleoli.
- Fracture to distal tibio-fibular jt or distal malleolus (either one) fracture.
3) When talus rotates / spins (IR and ER of talus)
- Lateral moves more since it has the larger facet. AND remember the medial side has the large strong deltoid lig, where the lateral has the 3 smaller weaker collateral ligs (causing more motion on lateral side).
1 T or F: The subtalar joint actually has 3 portions
- Explain each different portion / facet
1A) Which one is the 'subtalar jt proper'
- But does the 'subtalar jt' include them all?
1B) What is name for the most anterior portion of this 3 part joint
- What type of joint is this?
1C) What types of joints are the other 2
1D) True or False: These 3 joints allow tri-planar motion
2) The dome (and thus trochlea) sits on top of what part of the talus
3) What is the bony projection on the front and medial part of the calcaneus
- Another name for this?
- Is it on medial or lateral side?
- How will you remember it is on the medial side?
- Why is it have 'tali' in the name if it is the calcaneus bone?
- What attaches here
4) Is the subtalar joint a synovial joint
5) What is the space just in front of the posterior main part of the subtalar joint facet and the anterior portion of the peanut shaped joint / facet (sustentaculum tali)
- What fills this space
6) So what binds the talus to the calcaneus
- Which of these is the PRIMARY restraint
7) The anterior portion of the subtalor jt (the peanut shaped facets) ... that space is shared with what joint
- Does that anterior portion (peanut facets) of the subtalor joint do any weight bearing?
- What type of movement happens at this joint
8) The head of talus articulates with what bone?
- The head of calcaneus articulates with what bone?
- Does the calcaneus articulate with the navicular?
9) Explain the AOR for the subtalar joint
- Angle from inferior to superior
- Angle from posterior to anterior
10) Main motion at the subtalor joint?
- Pronation of the foot is also _______
11) In OPEN CHAIN, if you do supination motion of the foot, will the calcaneus or talus be the more mobile member?
- Is supination motion of the foot / calcaneus a valgus or varus motion
- Is this inversion or eversion
- Will the front part of the calcaneus do AB/ADduction?
- Will the front part of the calcaneus do Dorsi/Plantarflexion?
12) In OPEN CHAIN, if you do pronation motion of the foot, will the calcaneus or talus be the more mobile member?
- Is pronation motion of the foot / calcaneus a valgus or varus motion
- Is this inversion or eversion
- Will the front part of the calcaneus do AB/ADduction?
- Will the front part of the calcaneus do Dorsi/Plantarflexion?
13) In CLOSED CHAIN, if you do supination motion of the foot, will the calcaneus or talus be the more mobile member? Why?
- Is supination motion of the foot a valgus or varus motion at the calcaneus
- Is this inversion or eversion
- Will the front part of the calcaneus do AB/ADduction?
- Will the front part of the talus do Dorsi/Plantarflexion?
14) In CLOSED CHAIN, if you do pronation motion of the foot, will the calcaneus or talus be the more mobile member?
- Is pronation motion of the foot a valgus or varus motion at the calcaneus
- Is this inversion or eversion
- Will the front part of the calcaneus do AB/ADduction?
- Will the front part of the talus do Dorsi/Plantarflexion?
15) Take home point ... in open chain, does calcaneus or talus move?
- During closed chain, does calcaneus or talus move?
- So motion during open chain happens where
- Motion during closed chain happens where
16) Closed pack position of subtalor joint is in what position
17) If I do inversion of the foot, which way does my tibia rotate?
- If you do eversion of the foot, which way does the tibia rotate?
- T or F: torsion of the tibia is tied to subtalor supination and pronation
- You have an inferior facet that is the large main one that articulates with the calcaneus posteriorly (posterior on the talus). This is mainly for weight bearing.
- There is a peanut shaped facet more anteriorly (but on inferior side of talus) that can be 1 or 2 facets. But it articulates on the anterior / head portion of the calcaneus. This is mainly for the talus articulating on the calcaneus for tilt and torsion (or inversion / eversion).
- The last/3rd one is where the head of the talus articulates with the navicular bone
1A) The main one is the one that the talus sits on ... so the posterior facet on the calcaneus.
1B) Talonavicular joint
- Ball and socket
2) Body (the head and neck are anterior to the dome)
3) Sustentaculum tali
- Talor shelf
- Because the talus directs medially to articulate with the navicular bone, where the calcaneus directs more lateral to articulate with the cuboid bone.
- It is the portion that articulates with the talus (or holds the talus up on that shelf)
- Spring ligament
5) Sinus tarsi
- Talocalcaneal interosseous ligament (which connects calcaneus to the talus)
- Mainly that talocalcaneal interosseous lig. But also remember the fibular-calcaneo lig on the lateral side, and the Tibiocalcaneal (band) part of the deltoid lig on the medial side ... these both bind the calcaneus to the malleoli, thus creating apposition between the talus and calcaneus holding them in place.
- Talocalcaneal interosseous lig
7) Talo-navicular jt.
- YES. Not the majority, but it does.
- Mainly eversion/inversion
- A tiny bit yes.
9) It is complicated. It goes from posterior to anterior in a diagonal direction medially, and it goes from inferior to superior also diagonally oriented upward, and the talus rotates around that axis.
- 45 degrees
- 16 degrees
10) Inversion/Eversion (or supination/pronation)
13) Talus (in open chain the more distal member moves more, but in closed chain the more proximal member moves more)
- NEITHER - the talus ABducts
- Dorsiflexion (in open chain the calcaneus would plantarflex, but it can't now, so talus dorsiflexes)
- NEITHER - the talus ADducts
- Subtalar joint
- Up in ankle joint (some at subtalor joint)
16) Supination (inversion)
1) What is the spring ligament ... where is it ... what is it's purpose
- Another name for it
- T or F: The head of the talus is essentially wresting over the spring ligament?
- T or F: The spring ligament does some weight bearing
1) Main ligament on medial / plantar side of foot ... goes from sustentaculum tali to the navicular bone ... connects those two bones to maintain medial longitudianl arch.
- Plantar calcaneonavicular lig
1) If you stand from behind a patient and look at their posterior tibia in relation to the angle of the calcaneus, how would calcaneal valgus look?
- Is calcaneovalgus a supinated or pronated foot?
- Is this eversion or inversion
- Is this close or least pack position
2) So is calcaneovarus same as pronation or supination
3) Full ROM of the subtalor jt is (how many degrees)
- How much of that is from inversion vs. eversion
4) What is the neutral position of the subtalor joint
5) T or F: the subtalor joint is where motion happens if you walk over unneven ground, while keeping the tibia vertical
6) During normal walking or running, when you step down you want the subtalor jt to be as close to possible of subtalor neutral. But then does the calcaneus move into a supination or pronation motion?
- That is close or least pack?
- Then as you are flat footed and dorsiflexed ready for push off, what happens to the subtalor joint
7) Why would you land in a more supinated position when touching down during gait?
***** 8) T or F: When we say pronation and supination at the foot, that motion is happening at the subtalor joint primarily.
1) The bottom portion of the calcaneus would be lateral, top portion more medial.
3) 30 degrees
- 20 degrees (of the 30) is from inversion, 10 from eversion
4) When the medial and lateral part of the dome protrude equally beneath the malleoli.
- Moves into supination/inversion (close pack)
7) It is all about shock absorption, allowing foot to descend (pronate) to absorb shock). Otherwise if you landed in full pronation, you'd have no shock absorption. You need to be in supination to allow you to descend into pronation (which is shock absorption)
BELOW ARE FLASHCARDS ON ANKLE 2
1) If you want to control the foot, what should you control.
- Why? What does that mean?
2) What is the joint between the hindfoot and midfoot?
3) The medial part of the transverse tarsal joint is part of what other joint complex?
4) The lateral part of that joint is articulations of what bones
- How are these two bones held together
- T or F: The short and long plantar lig's are L.A.A.D.
5) T or F: the transverse tarsal joint is one large joint with a capsule and joint cavity
- Which side of this joint is more rigid or less moving?
6) Would the navicular and cuboid bones move more or less than the hindfoot bones
1) Calcaneus / subtalor joint
- Because it controls everything distally ... things that happen in the mid and forefoot are reactive to what is happening in the hind foot.
2) Transverse tarsal joint (midtarsal joint)
3) Subtalor joint complex where talus articulates with navicular (talonavicular jt).
4) Calcaneus and cuboid
- Lateral band of the bifurcate lig (calcaneocuboid lig) ... and the short and long plantar lig's (more on plantar side, but support those two bones).
5) False. It is technically seperated into two portions (medially and laterally).
- Lateral (the medial side has more of an arch for weight bearing / shock absorption).
1) When is the transverse tarsal joint in closed pack position
- When is this joint in least pack
2) If you are weight bearing, will the proximal or distal foot bones be more mobile
- So in NWB (open chain), are the proximal or distal bones more mobile
3) Can the navicular move superiorly and inferiorly with respect to the talus?
- Can the navicular move medially and laterally with respect to the talus?
- What limits or checks this motion
4) T or F: Dorsiflexion of the talus with respect to the navicular is the same thing as the navicular moving plantarly with respect to the talus
- If the navicular moves medially, would that be the motion of supination or pronation
1) When the hindfoot is in supination
- Capuslar ligs dorsally and plantarly, bony apposition, spring ligament
1) Is the calcaneus and cuboid bones articulation the same as the ball and socket motion/joint of talus with navicular?With movements of the calcaneus and the cuboid
- Explain how it is different
- What limits this gaping
2) If the cuboid moves inferiorly (plantarly) with respect to the calcaneus, is there gaping?
- What stops this motion
- Do the L.A.A.D. help with this?
3) Does the cuboid move medially and laterally on the calcaneus
4) If you are NOT weight bearing, will the calcaneus or cuboid move more (in these motions from the few above)
- What about during weight bearing
- So in closed chain, will the proximal or distal member be the mobile member
- The calcaneus anteriorly has a slight lip dorsally, so as cuboid moves dorsally (superior) it hits the lip and then gaps inferiorly / plantarly.
- Plantar calcaneocuboid lig (and the L.A.A.D. ... long and short plantar lig's)
- The dorsal capsular lig
- Calcaneus (proximal moves more during weight bearing).
1) What is the joint between the bases of the metatarsals and the distal tarsals
2) Distal cuboid bone articulates with what
- Distal Navicular articulates with what?
- 3 cuneiform bones articulate with what bones distally
3) T or F: The 1st cuneiform and 1st metatarsal have their own joint capsule?
- T or F: The 2nd and 3rd cuneiform bones and 2nd and 3rd metatarsals have a shared joint capsule
- The cuboid and 4th and 5th metatarsals share their own joint capsule
- So will inflammation of the joint between cuboid and 4th and 5th metatarsal also manifest in inflammation of the 2nd and 3rd metatarsals with their cuneiform bones?
- Do all these joint capsules have dorsal and plantar capsule lig's
- What type of joints are all of these
4) Of all 5 metatarsals, which one is the most stable (least mobile)
1) Tarsometatarsal joint
2) Bases of metatarsals 4 and 5
- 3 cuneiform bones
- Bases of first 3 metatarsals
- NO, they are seperate.
- Plane joint (book lying on a surface)
4) 2nd metatarsal
1) The feet have 'Rays' ... explain each and what it included in each:
2) So rays 1-3 proximally are articulating with what
- T or F: So, navicular issues will impact rays 4-5
3) T or F: The cuboid bone is included in rays 4-5, like the navicular with rays 1-3?
4) Which ray is the least mobile / most fixed?
- Which are most mobile
- Which side of the foot has more joint play
5) T or F: each of the rays can both dorsi and plantar flex?
6) T or F: If you think of the 1st metatarsal articulating at the medial cuneiform (really navicular), dorsiflexion of the ankle jt is flexion or extension of the 1st metatarsal?
- The 1st metatarsal's movement is primarily medial/lateral or superior/inferior?
- Metatarsals 4-5 have what movement
- Ray 1: Medial cuneiform, 1st metatarsal, phalanges of D1
- Ray 2: Intermediate cuneiform, 2nd metatarsal, phalanges of D2
- Ray 3: Lateral cuneiform, 3rd metatarsal, phalanges of D3
- Ray 4: 4th metatarsal, phalanges of D4
- Ray 5: 5th metatarsal, phalanges of D5
2) Navicular bone
- False: Navicular issues will impact rays 1-3
4) Ray 2
- 1st and 5th
- They also have flexion and extension, but curve/rotate much more in inversion/eversion (or abduction and adduction ... more curving down and in the further you go laterally).
1) Talus will point down the medial or lateral longitudinal arch
2) Looking at the MEDIAL aspect of the foot ... As you supinate the hind foot, WITH YOUR FOOT FIRMLY PLANTED ON THE GROUND DURING WEIGHT BEARING, where does MOST of the motion come from?
- What is the motion of the calcaneus
- What is happening at the talus
- What happens to the navicular
- What happens to the 1st ray
- This strange motion is called what:
3) Looking at the MEDIAL aspect of the foot ... As you pronate the hind foot, WITH YOUR FOOT FIRMLY PLANTED ON THE GROUND DURING WEIGHT BEARING, where does MOST of the motion come from?
- What is the motion of the calcaneus
- What is happening at the talus
- What happens to the navicular
- What happens to the 1st ray
- This strange motion is called what:
4) If your foot is firmly planted on the ground (closed chain) ... as you supinate the hindfoot, the 1st ray will dorsi or plantar flex?
- What will the lateral (3-5) rays do?
- During open chain, what would rays 3-5 do during supination?
- What does ray 2 do?
5) If your foot is firmly planted on the ground (closed chain) ... as you pronate the hindfoot, the 1st ray will dorsi or plantar flex?
- What will the lateral (3-5) rays do?
- During open chain, what would rays 3-5 do during pronation?
2) Subtalor joint
- Supination or inversion (or bottom aspect of calcaneus moves more medially and top rolls laterally).
- It rises upward and laterally (with the calcaneus)
- It also follows the talus in the same motion
- IT PLANTAR FLEXES (OPPOSITE MOTION) to keep the forefoot on the ground.
- SUPINATION TWIST
3) Subtalor joint
- Pronation or everting
- It rotates down and medially (with the calcaneus)
- It also follow the talus in same motion
- The ground reaction force forces the 1st ray into DORSIflexion
- Pronation twist
- Ground reaction force will shove them into dorsiflexion
- They'd just keep going into inversion and plantarflex.
- Ray 2 never really moves.
- Plantar flex (to stay on the ground)
- They keep doing eversion and dorsiflex
1) With the metatarsal phalangeal and interphalangeal joints of the foot, is the distal portion of each of these bones convex or concave?
2) T or F: The metatarsal phalangeal and interphalangeal joints are extremely similar to those in the hand?
- What does that mean?
- Will the collateral lig's of the foot (toes) get tight during flexion or extension
- Purpose of the volar plates
- Where are the volar plates in the foot
- Why doesn't Big Toe's MTP joint have volar plates
- What muscle attaches to these (from point above)
- What passes through these sesamoid bones?
3) When you do weight bearing on the foot, where does the weight bearing happen
- They have capsules, collateral ligaments, volar plates, extensor hoods, etc.
- Help protect capsules from tendons pull, protect capsules from constant force from the ground.
- MTP joints 2-5, and all IP joints (including big toe)
- It has 2 sesamoid bones because it does significant weight bearing
- Flexor hallucis brevis
- Flexor hallucis longus
3) Calcaneus, metatarsal heads, and somewhat the toes.
1) What is the 'metatarsal break'
- T or F: This is a straight medial-lateral line?
2) What type of joints are the MTP joints of the foot
- How many degrees of freedom do you have at these joints
3) For Metatarsal 1 at the MTP joint, how much extension do we ideally want/need for gait
- What about phalanges 2-5
- How much flexion do we have at the MTP joints
- Do we really need flexion at the toes / MTP jts during/for gait?
1) The area of metatarsal heads where they extend during gait (you'll see a line in your shoes).
- False. It is diagonal.
- 2 degrees (flex/extension and ab/adduction)
3) 60-100 degrees
- 60-80 degrees
- 25-30 degrees
- Not really no
1) What connects the hindfoot to the forefoot
- Where does this attach on both ends
- Does it incorporate the volar plates of the MTP jts
2) As you are in gait and your heel is off the ground and your weight is on the balls of your foot, what is happening to the plantar aponeurosis?
3) If you have a supinated foot with a high medial longitudinal arch, what is happening to the plantar aponeurosis
- Can you stretch the plantar aponeurosis?
4) What is the windlass effect / windlass mechanism?
- So if you dorsiflex the big toe, what happens to the plantar aponeurosis?
5) T or F: the distal attachment of the plantar aponeurosis is the head of the 1st metatarsal (metatarsals 1-5)
6) Will the windlass mechanism shorten or elongate the sole of the foot
- What will this do to the medial longitudinal arch
7) So the windlass mechanism is pronation or supination of the foot?
1) Plantar aponeurosis
- Calcaneal tubercles, base of proximal phalanges
2) It is tightening
3) It is very tight
- Some, but not a lot
4) Essentially is it having a rod from calcaneus up to the talo-navicular joint (medially), and another rod from the talo-navicular joint down to the base of the proximal phalanx. Then there is a spring from the base of the proximal phalanx back to the calcaneus that acts as the plantar aponeurosis. When you go up on the ball of your foot, the plantar aponeurosis is pulled tighter (shortening) and this actually helps provide more stability when up on the ball of your foot to weight bear.
- It is pulled tight/stretched. It moves the calcaneus distally (forward), and / or the metatarsal head proximally.
5) False. It attaches to the base of the proximal phalanges.
- Heighten it
1) How many arches of the foot?
- What are they
- Which of the two longitudinal arches undergoes the most change during gait?
- There is a moveable and non-moveable transverse arch. Explain
2) If you weight bear, will the distal transverse arch widen/flatten or become more narrow/curved?
3) Where do you weight bear on the sole of your foot
- T or F: The weight bearing at metatarsal head 1 is actually shared between metatarsal heads 1 and 2
4) What supports the lateral longitudinal arch
5) What supports the medial longitudinal arch
- T or F: the spring lig is the most important part of maintaining the medial long. arch
- T or F: The long and short plantar ligs, and plantar aponeurosis, contribute to helping maintain both lateral and medial long. arches
6) T or F: Both the medial and lateral longitudinal arches are also supported by muscles
7) How is the distal transverse arch supported primarily
- So what happens to this muscle over time, and why?
- So if the distal transverse arch, the more mobile one, falls, it is because of what:
- T or F: There is not a lot of good ligaments here to support the distal transverse arch
8) What is morten's neuroma
- How might you quickly fix this?
- Lateral and medial longitudinal, and 2 transverse arches (proximal and distal)
- Non-moveable will be the proximal transverse arch (which is the talus bones: navicular, cuboid and cuneiform's). The moveable is the distal transverse arch along metatarsal heads. The distal one will descend / flatten during pronation of gait.
3) Calcaneus, and then metatarsal heads 1 and 5
4) L.A.A.D. (short and long plantar lig's) and plantar aponeurosis ... and muscles
5) Spring ligament (long plantar lig, short plantar lig, and plantar aponeurosis) ... and muscles
7) Transverse head of the Adductor Hallucis muscle
- We weight bear on the metatarsal heads, and this muscle is right under them, and so it gets worn down or denervated or ruined over time (weak, thin, and denervated).
- Transverse head of the Adductor Hallucis muscle getting damaged.
8) The digital nerves that bifurcate to supply digits / toes, they pass right at the point of the transverse head of the adductor hallucis - so if this muscle gets weak, the metatarsal heads can descend and press down and impinge these nerves and then scar and/or send zinging pain down into toes.
- Roll up some tape, put it under the distal transverse arch and it will allieviate the zinging pain down into the toes.
1) During gait, right when the calcaneus hits the ground, what are the dorsiflexors (anterior compartment of the leg) doing?
2) Foot slap is associated with weakness in what m's
- So what do people do to compensate for this?
- How will this effect stepping onto the ground with that weak foot
3) T or F: Tightness of the tibialis anterior muscle will pull up on the medial longitudinal arch
4) What is pes cavus
5) T or F: Toes have extensor hoods as well
- So where does extensor hallucis longus and extensor digitorum longus muscles attach
6) Good L4/L5 muscles to test for L4/L5 innervation
- Good L5 muscles to test for L5 innervation
7) Weakness of extensor hallucis longus would be called or viewed as:
- How would it impact putting on socks or shoes?
1) Eccentrically contracting to slowly help foot descend into the ground.
2) Dorsiflexors (probably the big one - Tibialis Anterior)
- Flex hip and knees more
- Calcaneus won't hit first, the toes will.
4) Pes cavus is a foot morphology characterized by high medial longitudinal arch of the foot that does not flatten with weightbearing. (Pes is FOOT).
- Technically at the base of the proximal phalanx, and then the extensor hood mechanism extends from there.
6) Tibialis Anterior
- Extensor hallucis longus
7) Turf toe
- Makes it hard since it will fold/flex as you are trying to put those on.
1) In general, when you denervate a nerve, what happens to the muscle(s) that nerve innervates initially?
- Over time what happens to those muscles?
2) If your extensor hallucis longus (or extensor digitorum longus) gets tight, what will you see:
- At the MTP joint dorsally?
- With the toes?
- What would happen to the volar/plantar plate during this situation
- If there is not an extreme case, how might you eye ball it to see this happening?
3) T or F: The extensor digitorum longus tendon distally will attach at the distal phalanx
4) Of the anterior compartment m's of the leg, which of those 4 is the weakest dorsiflexor
5) Which muscle is the only one of the anterior compartment of the leg that helps with eversion of the foot?
- So if tibialis anterior and extensor hallucis longus were damaged, every time you dorsiflexed the foot, would you invert or evert?
6) If your toes are draging during gait, what might be the reason
- How do people typically compensate for this
7) If extensor digitorum longus is tight, what will happen
- What is the long extensor muscle of the hand/forearm called:
8) What is the function of the fibularis tertius
- Does it contribute to dorsiflexion?
- Does it contribute to inversion or eversion?
- What is this muscle MAINLY used for?
1) They get long and floppy
- They shorten, atrophy, get hard, and get fibrosis.
- Well the dorsal side is pulling into extension, which makes the plantar m's get stretched which pull the toes into a flexed position. Looks like curled toes.
- It is pulled distally ... leading to metatarsalgia
- Look at the dorsum of the IP jt of the big toe and see if there is hardening / callus from being rubbed on shoe.
3) Technically that is false. It attaches distally at the base of the proximal phalanx via the extensor hood.
4) Extensor digitorum longus.
5) Extensor digitorum longus
- Tibialis Ant. and Extensor hallucis longus are oriented so medially on the foot that they create an inversion of the foot during dorsiflexion, so because the extensor digitorum longus has tendons on the lateral aspect of the foot, it balances all the dorsiflexors pulls (especially inversion) by helping create an eversion torque to balance things out.
6) Weakness of the extensor digitorum longus (and possibly extensor hallucis longus too).
- Semi steppage gait (flexing hip and knee more)
7) Hyperextension of MTP joints, and claw toes since the flexor muscles on plantar side will pull toes down (same concept as above).
- Extensor digitoum muscle (not longus)
8) It is essentially another head of the extensor digitorum longus.
- Yes (not a lot, but yes)
- Eversion (a little)
- TENDON DONOR.
1) Posterior compartment muscles of the leg primarily together do what action
2) What are these m's innervated by (peripheral nerve and nerve roots)
3) What is the strongest tendon of the body?
- About what amount of force can it sustain
- T or F: The Achilles is the most frequently ruptured tendon in the body?
4) Best blood supply to a tendon is from what?
5) The Achilles tendon contributes more to calcaneal inversion or eversion? Why?
- So would the gastrocs help do more pronation or supination of the hindfoot?
6) If your gastroc is tight, would you have limited plantar or dorsiflexion
7) What is pes equinus
8) During gait (or running), what is the role of the soleus
- A weak soleus muscle would result in what 2 things during gait?
9) Tightness of the soleus would be manifested how?
- People walking with a 'spring in their step' is called:
10) Tight soleus would shove the foot into dorsi or plantar flexion
- If you stand flat footed in this scenario, what happens at the knee and hip
- What happens to posterior knee capsulse
- How can you fix this?
11) Purpose of plantaris muscle?
12) Is the gastroc or soleus the 2 joint muscle of the superficial posterior compartment of the leg?
- T or F: Technically the gastroc is a 3 joint muscle?
1) Plantar flexion
2) Tibial nerve ... S1 and S2
3) Achilles tendon
- 1/2 a ton
4) The muscle belly itself
5) Inversion. The majority of the tendon is on the medial side, helping pull the cancaneus into inversion. Probably cause it helps put it into close pack position??
7) Extreme tightness of the gastrocs where you are essentially standing on tip toes since gastrocs are tight. Walking with a 'spring in your step.'
8) Thinking about where it attaches (back of the tibia/fibula), as the tibia rolls forward during gait (ankle rocker), the soleus is eccentric contracting to prevent too much ankle rocker movement.
- Excessive dorsiflexion, and unable to 'push off' and get plantar flexion during push off.
- Limited dorsiflexion during gait OR early heel rise (same thing). People walking on balls of their feet / spring in their step
- Pes equinus
- Knee goes into more extension, hip thus does more flexion to compensate
- It stretches more
- Not only stretch the triceps surae m's, but put some brace on pt to help get more dorsiflexion at the ankle to make all the jt alignments better.
11) Good tendon donar
- True. It crosses the knee, ankle, and subtalor jt.
1) Muscles of the deep posterior compartment of the leg
2) Innervation of the deep posterior compartment m's of the leg (peripheral and nerve roots)
3) Tendons of these m's go through what:
- Accronym to remember these
- What is at the bottom of this tunnel (or deep)
4) Does the deep posterior compartment m's attach to or control the calcaneus
- What is the main function of these m's
5) What is the innervation of the tibialis posterior muscle
- T or F: Like the tibialis anterior of the anterior compartment, the tibialis posterior is the big muscle of the posterior compartment
6) What muscle does eccentric control of pronation
- So during gait, what is the role of the tibialis posterior muscle
7) T or F: if you lose all innervation / contraction of the superficial posterior compartment of the leg, the tibialis posterior muscle can help to somewhat plantarflex the ankle in it's place.
8) Weakness of the tibialis posterior would be manifested how?
9) Sometimes people get a protrusion of bone on their medial and plantar foot proximally near the navicular bone. What is this?
- What muscle would this impact?
- Is it a sesamoid bone? Why?
10) What is equinovarus
- What does it look like?
- Another name for this
- How is this fixed?
11) When or why do we use the flexor digitorum longus muscle
- T or F: The flexor digitorum longus does weakly do plantar flexion
- T or F: The flexor digitorum longus does weakly do eversion of the foot
- How would tightness and weakness in this muscle be made manifest?
12) Which toes are absolutely necessary for function (gait, weight bearing, etc.)
1) Tibialis posterior, flexor hallucis longus, flexor digitorum longus
2) Tibial nerve (L4-S2)
3) Tarsal tunnel
- TDAVNH (Tom, Dick, And, Very, Nervous, Harry)
- Deltoid Ligament
- It helps plantar flex, and flex toes to get up on toes of your feet (flex them) ... and tibialis posterior supports the medial longitudinal arch and helps in inversion.
5) L4-L5 (Tibial nerve)
- True (2x CSA of other 2 muscles).
6) Tibialis posterior
- Eccentric descent of foot (medial long. arch) during pronation, and then concentric contraction during supination of foot.
- Over pronation of the foot
- valgus of the calcaneus
- And medial longitudinal arch / 1st ray gets flat footed, so you lose leverage / strength to bear weight and push off during gait.
9) Accessory navicular bone (sort of a sesamoid bone). Growth plate that doesn't fuse properly near the navicular bone in the foot, and results in an outgrowth of the bone.
- Tibialis posterior
- No. It doesn't improve angle of pull (even though the tendon is embedded into it).
10) Extreme tightness of the tibialis posterior. It pulls ankle and 1st ray into plantarflexion and extreme inversion, and hindfoot into varus.
- Extreme inversion where person is walking on lateral sides of their foot.
- CLUB FOOT
11) Obviously to flex toes, but also to eccentrically control dorsiflexion of the toes.
- False. It weakly helps with inversion
- Tightness would be claw toe, and weakness means when you leave ball of foot and need toes to push off, you can't do that.
12) Mainly 1st and 2nd toes
1) What muscles are in the lateral compartment of the foot
- These are innervated by what nerve
- Nerve roots?
- Their function
- The lateral compartment of the leg m's provide 2/3 of the torque for eversion. What provides the other 1/3
2) Does the tibialis posterior muscle or the fibularis longus muscle attach to navicular (on plantar side)?
- Does the tibialis posterior muscle or the fibularis longus muscle attach to 1st metatarsal (on plantar side)?
3) Does the fibularis longus plantarflex the ankle
- What is another role of the fibularis longus
4) If you have a weak fibularis longus, what does it result in?
- If you have a tight fibularis longus, what does it result in?
5) If fibularis brevis is weak, what happens:
- If fibularis brevis is tight, what happens:
6) He explained how if your superficial fibular nerve gets denervated, you obviously lose the lateral compartment of the leg. This results initially in floppy weak fibularis longus and brevis m's (resulting in more inversion and no eversion of the foot). But over time, these m's get fibrotic and tighten and thus pull foot into excessive eversion.
1) Fibularis longus and brevis
- Superficial fibular nerve
- Eversion and help with plantarflexion
- Extensor digitorum longus (communis) muscle.
2) Tibialis posterior
- Fibularis Longus
3) Yes (a little)
- support medial longitudinal arch
4) Weak: Lateral ankle sprains, and no counter force to the inverters of the foot (so you walk on the lateral side of the foot).
- Tight: Plantarflexed 1st ray (more pronated in that area)
5) Weak: Lateral ankle sprains, and no counter force to the inverters of the foot (so you walk on the lateral side of the foot).
Below are the flashcards on POSTURE
1) Define posture
2) T or F: It is pretty difficult to find someone with 'perfect posture'
3) What is the difference between standing and task related posture
- T or F: The environment impacts our posture? Example?
- Can your internal environment impact your posture
1) The average or typical alignment of the body segments relative to one another and with respect to the line of gravity.
- The ideal text book posture is rarely achieved ... only by very few.
3) Obviously standing is postural position when you are standing, where task related is any situation (typing on a computer, sitting in class, sleeping posture, watching tv, etc.).
- True. In the cold my posture is different than when it is hot outside. Or if I'm in a crowded place next to people (standing in a line). Or with a backpack over one shoulder, or holding a bag in one hand.
- Sure. Depression, confidence, excitement, embarrassment, PAIN - they all impact posture.
PRINCIPLES OF POSTURE
1) T or F: Faulty alignment results in undue stress and strain on bones, joints, ligaments, and muscles
2) T or F: Positions of joints indicate which muscles are elongated or shortened?
3) T or F: A correlation exists between alignment and muscle test findings?
4) T or F: Muscle weakness allows seperation of the parts to which the muscle is attached?
5) Muscle shortness holds the parts to which the muscle attaches closer together
6) Stretch weakness can occur in one-joint muscles that remain in an elongated condition? Why?
- What is stretch weakness:
- T or F: you can establish a new L sub 0 for your muscle(s)
- What is L sub 0 of a muscle
- Does this apply to 2 joint muscles? Why
7) T or F: Adaptive shortening can develop in muscles that remain in a shortened condition
- What's an example of this
1) True (the more faulty the alignment, the more stress and strain)
3) ?? Iffy.
4) False (Position is more a neuromuscular issue vs. just muscular weakness ... or really strong muscles change body position as well)
6) False. Because a muscle that gets stretched doesn't necessarily mean it gets weak, it just creates a new L sub 0 and tests weak.
- When you do a strong MMT (break test) of a muscle that is elongated/stretched then it will test weaker than it should because it was on stretch it became weak
- True (if you chronically use muscle in an elongated position, it reaches a new L sub 0)
- The point where you get optimal / maximal contraction (so 60-70 degrees for knee extension).
- Not really since a 2 joint muscle might get elongated over one joint, but then it will be short over the other joint ... so the rule doesn't apply as well.
- If you chronically wear high heels, your soleus will shorten. Or posture forces hip flexion, iliopsoas will tighten and become shorter.
1) What is the plumb bob / plumb line
- What are the landmarks on someone for a plumb line (in the sagittal view)
- But you won't usually get both those (from point above) ideally perfect, so the starting position of plumb bob is where
- When you orient the plumb line from the external acoustic meatus to the calcaneal-cuboid joint, this is called _________, and why is it important with posture?
2) With respect to the plumb line, go through the IDEAL alignments for posture looking at someone in the sagittal view and where should plumb line go through in these areas:
- Trunk and L-Spine
3) T or F: typically in most people their heads are oriented slightly posterior the plumb line?
- T or F: Most people have forward shoulders
- Is AOR of hip jt anterior or posterior the 'ideal' plumb line? Why?
4) Now looking at someone in the frontal (anterior) view, where would the plumb line go?
- Explain briefly the 'ideal' posture (or plumb line) in this plane from head to toe
- T or F: with idealized posture (in frontal view) the line from both accromion's should be straight/level.
- With regards to the last point, is it ideal in most people? Why?
- T or F: Idealized posture is both iliac crests and greater trochanters are at the same height
5) In ideal posture, would the femur with respect to the tibia have a slight valgus or varus
- 'Physiologic valgus' is about what (in degrees)
6) Ideally we stand in a subtalor neutral position, but typically would the calcaneus be in slight eversion or inversion? Why?
7) If you look at the back of the legs / feet in a normal ideal posture, how many toes should you see (and will you see them on the medial or lateral side)
- This suggests slight medial or lateral rotation of the foot in normal posture
- The degree amount from the posterior part of the heel to the line of the 2nd ray is about how many degrees
1) The plumb bob or plumb line is the line of gravity ... the “plumb” (that is, what is exactly vertical, or true). It is a weighted object held from a string to provide a perfectly vertical line.
- Plumb line / vertical line goes cranially from the External auditory meatus down to the calcaneal cuboid joint (just anterior to lateral malleolus)
- Calcaneo-cuboid joint at foot (then you see how everything lines up from there ... ideally it goes through external acoustic meatus, but may not).
- Idealized line ... and everything else gets oriented around that idealized line.
- Head / Skull: is positioned over BOS. Even between ant/post (meaning head is not too far anterior or posterior). Plumb line runs through the external acoustic meatus.
- C-Spine: Through odontoid process (dens), through POSTerior vertebral bodies, and then the body of C7/T1
- Shoulder: A/C joint
- Trunk and L-Spine: From T1 to anterior part of the thoracic vertebrae, rejoins through body of T12/L1, then goes posterior part of Lumbar vertebrae
- Pelvis: Through L5/S1 and then more anterior on S2
- Hip: Through the greater trochanter
- Knee: Femoral condyles
- Ankle: Calcaneo-cuboid joint (just anterior to lateral malleolus)
3) False - it is anterior (MOST of us have a forward head)
- Anterior (because of anteversion of the hip)
4) Through the mid-line
- Through middle of the head, down through all spinous processes perfectly, through middle of sacrum, with equal distance between legs at knee and ankle.
- NO. Most right handed people have their right shoulder slumping down more inferiorly than their non-dominant hand (and visa versa).
- 5 degrees
6) Eversion, because weight of body standing will push weight into moveable medial longitudinal arch and create pronation / eversion of foot. Otherwise we'd stand on the lateral part of our foot.
7) 2 1/2 laterally
- 7 degrees
1) There are various 'types' of postures, and mainly you can categorize them into these types:
2) In the kyphosis-lordosis posture, how would these appear / what would they be doing:
- Thoracic spine
- Lumbar spine
2A) Explain the concept of short and strong muscles, and the 'stretch weakness' muscles concept in this posture
2B) What would correct this posture
3) T or F: The ASIS and PSIS should be in the same plane (in ideal posture)
- If looking at person from the front in a frontal view, the ASIS on right and ASIS on left should be level in ideal posture?
- Will it be this way in most people
4) In kyphosis-lordosis posture, will the hamstrings get shorter and stronger, or stretched and weaker
- So what would happen to the quads
*** SO, he said that the concept of a muscle being SHORT and TIGHT is absolutely true. But whether it is SHORT and STRONG is debatable, because MMT a shortened muscle is putting it into a position of normal strength, so do you really know whether it is 'strong' based on the muscle being shortened. He said you can't definitively prove that.
Similarily, the concept of a muscle getting stretched and weak is an 'iffy' concept since if you stretch a muscle, it gets a new L sub 0, and if you do a MMT it might appear they are weak because they've been stretched, when really they just have a new L sub 0. SO, IT IS NOT REALLY A WEAKNESS ... IT IS A TEST WEAKNESS.
- Kyphosis-Lordosis posture
- Sway Back Posture
- Military Posture
- Head: forward
- C-Spine: Distal/inferior/lower c-spine flexes, and proximal/superior/upper c-spine extends
- Scapula: ABduction (protraction)
- T-Spine: kyphosis
- L-Spine: Lordosis
- Hip: Anterior pelvic tilt ... so hips are slightly flexed
- Knees: Posterior or extension
- Ankles: not really effected
2A) In upper c-spine because this person (in kyphosis-lordosis posture) is extending the head back, those cervical extensors become short and strong (or ... will test strong in a MMT). Same with hip flexors. But the thoracic erector spinae m's are stretched more, so if you do MMT on those (putting person in almost fully contracted position) they will test weak (same with hamstrings). That is the 'stretch weakness' ... when in reality it just has a new L sub 0. And shortened 'appear' or test stronger but really they are just in more of a L sub 0 position so seem stronger when tested. SO it is really just testing stronger or weaker.
2B) Stretch the upper c-spine m's, and strengthen the heck out of the thoracic spine m's.
- Most people don't have an ideal posture :)
4) Stretched and weaker
- They'd become short and strong (in other words a tight rectus femoris)
1) What is the BIG difference between the kyphosis-lordosis and the sway back postures?
- With Sway Back, what is the pelvis doing?
- With kyphosis-lordosis, what is pelvis doing?
2) Once you start at the hip and see what is happening at the hip, then you just go north and south through the kinetic chain and essentially you can assess and derive how the body will compensate as a result of what is happening at the hips/pelvis. But look at hips first ... is it anterior or posterior pelvic tilt, and then you can basically assume how other body parts from there will compensate and bend to accommodate that non-ideal posture
3) Can posture be changed?
- An example proving it can be change?
4) In the military posture, how would these appear / what would they be doing:
- Thoracic spine
- Lumbar spine
5) What might be the issue with military posture
6) What m's would be short and strong in military posture
- So what m's would be elongated and weak
1) Pelvis orientation.
- Anteriorly displaced (or forward), and a posterior pelvic tilt
- Anterior pelvic tilt
3) It is really hard to do, but yes it technically can. You can't change bony alignment or a lifetime of poor posture, but you can impact it yes.
- Military posture
- Head: Neutral
- C-spine: Good alignment
- Scapula: Slight retraction
- Thoracic spine: Normal
- Lumbar spine: Hyper-Lordosis
- Hip: Anterior pelvic tilt (so probably some hip flexor tightness)
- Knees: A little of hyper-extension
- Ankles: Normal
6) It is not natural, and the straight knees cause poor circulation, which could result in blacking out.
7) Hip flexors, lumbar spinal m's, and probably rectus femoris
1) T or F: Nobody's body is perfectly symmetrical
- T or F: We as therapists can change/impact posture
- T or F: But we as PTs also have to be realistic with ourselves and our pt's that we can't easily change a lifetime of habits and posture. It takes time, and we can't change it all.
2) The most common reason why people are NOT symmetrical is because of:
- So a left handed person will have their left or right shoulder higher?
- For that left handed person, will the left or right iliac crest typically be higher. WHY?
- So non-dominant sided pelvis will be higher or shorter?
- In this same example, if left shoulder is lower (and thus left iliac crest is higher), then which way would spine curve?
- From point above, the curvature of the spine will be concave to strong or weak side?
- So in this case, is left upper trap long or short
- Is erector spinae m's on left side short and strong or long and weak
- Would gluteus med/min m's be in AB or ADduction on the dominant side?
- True (to an extend ... as explained above)
2) Your handedness ... if you are right handed, your right shoulder will be a bit lower.
- Right shoulder would be higher, left shoulder would be lower on a left handed person.
- Left sided iliac crest will be higher. Because you often weight bear on your strong side, which causes strong shoulder to descend, but then you hike up the hip on that side to compensate. Over time, this abnormal development morphs into your overall posture.
- Laterally ... top and bottom portions to the left (or c shaped to the dominant side)
- STRONG (dominant)
- Dominant side would be short and strong.
- Adduction ... or stretched
Now looking at postural changes within children during development
1) During development, in mom's womb, you are curled up in a c-shaped ball and primarily have movement in the sagittal plane. But ...
- During the first 6 months of life (out of the womb), you primarily lie on the ground and develop what muscles most
- Then around a year, you start to stand, and develop
2) Initially are babies/children bow legged or knock kneed? Why?
- So is genuvarus or genuvalgus the norm in children
- About what age do we get rid of the varus and have more of a normal straight leg?
3) How is the arch(es) of the foot in babies
- So are babies feet supinated or pronated more (initially)
- T or F: Babies don't develop their longitudinal arches in first year since they aren't walking
- Why does weight bearing actually develop the arches (seems the opposite would happen)
- T or F: A 1 yr old is more flat footed than a 5 year old, but the 5 yr old's arches are still developing?
4) Explain what happens at the acetabulum / hips with a baby during development
5) T of F: Development happens caudally to cranial
6) Why do kids have pouchy bellies?
7) About when do kids start showing hand dominance
- And thus what age would you see hand dominance postural changes?
8) T or F: The pelvic tilt will be more anterior pelvic tilt as a child
9) With regards to flexibility in children:
- Can babies lean forward and touch their toes?
- What about kids aged 5-12, how is their flexibility?
- WHY (from the last point)
- So what are growing pains?
- At what age does the skeletal growth essentially stop, muscle growth catches up, and flexibility is restored
- In order to touch your toes, what do people need to have (flexibility wise) or be able to do
- C-spine muscles extend, creating lordosis in c-spine
- Lordosis of lumbar spine
2) Bow legged (Wider base of support)
- Around 2
3) Pretty flat
- It is based on development happens cranial to caudal, and so as the lower muscles start to develop and get tone, they pull on arches which form the arches. But this doesn't happen till you start walking. Muscle tone of those leg muscles isn't developed yet in a baby since they don't have to use those m's to walk.
4) Early on the femur head/neck is significantly anteverted. But as the baby does weight bearing, the acetabulum descends more and femur head/neck goes into more retroversion so the femur head and acetabulum can become more congruent for weight bearing.
5) False. It is cranial to caudal
6) Small trunk, little abdominal muscle tone, and lots of guts :)
7) Age 4-5
- Easily. Babies are very flexible
- It progressively gets worse as they age through childhood / puberty.
- They have excessive skeletal growth, and muscles can't keep up
- Basically the bones are growing faster than the muscles and pulling the muscles, which causes pain.
- 18 ish
- Flexible hamstrings, flexible erector spinae, able to protract scapula
1) With regards to postural changes of the AGING population ...
- Why does posture change with age
- Describe how exercise can help change posture during aging, and what exercise can't change:
2) In general what happens during aging (getting older) at the:
- Thoracic spine:
- Lumbar spine:
3) If someone has OA, will the lumbar lordosis increase or decrease.
4) T or F: An elderly person will have more scapular retraction?
- How can you change excessive shoulder protraction in an older person
5) Is walking straight up and down (as far as LE joint alignment), or walking with hips and knees both flexed harder?
6) What is Dowager's Hump
- Over time through wear and tear our bodies get bruised, broken, accidents, etc. ALSO, connective tissue (ligs and muscle) gets worn down and weak and thus elongate and change body positioning. Plus the IV discs get worn down too. We don't correct poor posture and then it gets worse over time.
- Exercise can certainly delay IV disc degeneration or connective tissue breakdown (but can't change it). It strengthens muscles which help with alignment / posture. But it can't correct IV disc degeneration, it can't activate neuropathies, it can't change bony alignment.
- Head: Bent forward (anterior)
- C-spine: Lower c-spine flexed, upper c-spine extended
- Thoracic spine: Kyphosis
- Lumbar spine: Lordosis
- Hip: Anterior pelvic tilt (tight 1 joint hip flexors from sitting a life time at work).
- Hip: More hip flexion
- Knees: Flex knee to help get tibia under you since hips are so flexed. Short hamstrings from sitting a lot over years.
- Ankles: Since hips and knees are flexed, ankles will plantarflex.
- If you have OA, you don't want facet joints doing apposition (that will be painful). So you flex lumbar spine more to alleviate the OA pain from bone on bone apposition.
4) False. They'll have more protraction
- Doing retraction strengthening exercises is NOT enough. Even stretching pectoralis major will help, but not be enough. You can and should do that, but they also need a neural element to retrain the neural firing.
5) Hips and knees flexed
- The LOG falls posterior to the knee joint AOR and anterior to the hip joint AOR, forcing the knee into more flexion and hip into more flexion, thus creating way more torque and muscle contraction at hips and knees to counteract the GRF ... thus needing more energy to complete motion.
6) Dowager's hump: An abnormal outward curvature of the thoracic vertebrae of the upper back creating more thoracic kyphosis and lumbar lordosis (which actually results in the person become shorter). Abdomen thus sticks out more since back is being compressed. IV discs get compressed and shortened. Also compression of the front portion of the involved vertebrae due to osteoporosis leads to forward bending of the spine (kyphosis) and creates a hump at the upper back.
1) Explain the 'forward head posture' position
2) What is the 'round back' posture position
- If you have a pt bend down and you see hyper-kyphosis of the thoracic area, what could this posture be the result of:
3) What is 'S shaped curve' posture of the spinal column
- What are 2 ways to detect if someone has scoliosis
- What might be a reason someone gets scoliosis
- Do men or women more often suffer from scoliosis?
3A) How do you actually objectively / officially measure to see if someone has scoliosis. What is the method called?
- Explain how it is done:
- Explain the varying degrees and what needs to be done at these varying degrees:
3B) Can we as PT's really change scoliosis?
3C) T or F: most of the scoliosis development happens during childhood. Scoliosis doesn't develop further much during adulthood (but may get a bit worse during older years)
3D) Will exercise reverse scoliosis?
- What will exercise do for those with scoliosis
3E) Does bracing reverse scoliosis
4) What is the turned head/neck to one side
1) Lower cervical spine is in flexion, and upper cervical spine is in extension - head thus goes forward/anterior.
2) This is thoracic kyphosis
- Osteology / bone problem
- IV disc issues
- Over stretched thoracic spinal m's
- Poor posture that gets worse and worse over time as COG falls and moment arm gets larger
- Tightness in lumbar spine
- Tight hamstrings
- Look at them from posterior view to see if spine is S shaped. Also, have them bend forward and place a ruler or level on their back (to gauge level alignment of both sides). If one side of their back protrudes up/out, usually that is a sign of scoliosis as well (because the back will protrude since curvature of spine displaces rib cage).
- Could be vertebral column patho-development during childhood, or an injury reason, could also be a short leg (broke a leg as a kid and damaged epiphyseal growth plates) that was never corrected so shorter leg leads to curved spine one way.
3A) Cobbs Angle Method
- Draw a line from the top and bottom of the vertebrae where the curvature starts and ends. This angle is the cobbs angle (keeping in mind that on a radiograph it goes out laterally more than radiograph will capture, so they use geometry to measure angle).
- If angle is < 15 degrees: watch
- If angle is 15-40 degrees: brace
- If angle is 40+ degrees: surgery
3B) NO. Can't really change bony alignment. We can recommend strengthening exercises (not to change bony alignment) but to help strengthen m's to limit progression. You can also get pt a brace, or monitor to know when to recommend surgery.
- It helps give strength, improve cardio-pulm abilities, etc.
3E) NO ... it slows its progression, gives support, but doesn't reverse it.
4) Torticollis from tightness or denervation of SCM muscle.
1) With regards to the ASIS and PSIS alignment, how should these be aligned relative to each other in sagittal and frontal plan view
- T or F: Ideal posture is the ASIS and PSIS is perfect symmetry, but nobody is ideal
2) If you are looking at someone from behind, looking at their posture, what might be a cause or reason for these conditions:
- One scapula higher than another
- Scapulae in more abduction
3) If you are looking at someone from in front, looking at their posture, what might be a cause or reason for these conditions:
- Squinting patella's
- True of False: Squinting patella = mediallly oriented patella's = femur is laterally rotated
1) They should be aligned together / levle in both frontal and sagittal view.
- Tight pectoralis minor on the higher scapula side (or weak pectoralis major on low side) ... or, remember hand dominance causes one shoulder to be lower than the other.
- Weak rhomboid's or tight serratus anterior
- This is from too much anteversion at the head of the femur. The anteversion causes you to compensate by rotating femur in and that causes patella to go medially.
- False: Squinting patella = medially oriented patella's = femur is INTERNALLY rotated (to compensate for the too much anteversion at hip joint).
Below are flashcards on GAIT:
1) Define these terms below:
1A) Define Gait Cycle (GC)
- T or F: GC is a stride.
2) T or F: When we talk about gait from analyzing someone's gait, we are going to look at one side only
3) YOU MUST KNOW (memorize) these numbers below for the Gait Cycle:
- What % of the gait cycle is the stance phase
- What % of the gait cycle is the swing phase
- Why don't you do it based on time
4) During the stance phase, explain the 3 sub-phases and the % of time spent in that sub-phase
5) So using the right leg, explain ALL the phases step by step in the ENTIRE gait cycle:
6) During the first phase (the initial double limb stance), explain what is the MAIN thing happening in this first 0-10% phase of GC:
- Right when the foot hits the floor, this is called:
- Explain what happens, and % of Gait Cycle (GC) from point above:
- Right as the foot hits, it starts what motion ... or what EVENT?
- The rest of this 10% phase of initial double limb stance is called _________ and it is what % of the overall GC?
- Since Loading Response (LR) is 0-10%, does it thus include the initial contact phase (IC) since it was 0-2%?
- What is happening during LR
- When does LR end?
7) During IC, what is happening at the:
8) During LR, what is happening at the:
9) What are the EVENTS during gait cycle?
- How many events are there?
- Explain the ROCKERS (or events) that happen during the time while the foot is in contact with the ground (and what phase each rocker falls in):
10) Explain what happens to the pressure in the foot during midstance phase
11) What is the first 1/2 of single limb stance phase?
- What is the 2nd 1/2 of single limb stance phase?
- So what is happening during this 2nd 1/2 of single limb stance phase:
12) The 'controlled fall' phase is what phase:
- What is a 'controlled fall' and why would it happen?
13) During the midstance part of the single limb stance phase, what is happening with the other / contralateral limb?
14) During the terminal stance part of the single limb stance phase, what is happening at the:
15) The vigor of your pushoff determines your gait _______-
16) Now we move into the terminal double limb stance phase. What is the main sub-phase during this phase (the percent, and purpose)
17) Next is the swing phase
- What % is this of the GC?
- How many sub phases in swing phase? Name them
- What is the first sub-phase during the swing phase (with it's % and purpose)
- So you know when initial swing phase is done when what happens?
- What is the 2nd sub phase of the swing phase (with it's % and purpose)
- What is the 3rd sub phase of the swing phase (with it's % and purpose)
18) During the initial swing part of the swing phase, what is happening at the:
19) During the mid swing part of the swing phase, what is happening at the:
20) During the terminal swing part of the swing phase, what is happening at the:
- Gait: Repetitive sequence of trunk and UE/LE limb motions to move the body forward while maintaining stability.
- Step: Distance between one floor contact to the next contralateral floor contact of the feet
- Stride: Distance travelled between ipsilateral floor contacts (right foot strike to right foot strike = 2 steps = stride)
- Stance: Period of ground contact with a single foot
- Swing: Period of no ground contact with a single foot
1A) It is the stance phase (60% of GC) and swing phase (40% of GC) of 1 leg.
- Gait is both feet moving (obviously), but when we talk about and analyze gait events, we just look at one limb.
- Everyone's stride time is different
- Initial double limb stance: 10%
- Single limb stance: 40%
- Terminal double limb stance: 10%
- Initial double limb stance (10% of total)
Initial Contact (IC): 0-2%
Loading Response (LR): 0-10%
- Single limb stance (40% of total)
Terminal Stance (30-50%)
- Terminal double limb stance (10% of total)
Pre-swing phase as contralateral limb touches (50-
- Swing (40% of total)
Initial swing phase (60-73%)
Mid swing phase (73-87%)
Terminal swing phase (87-100%)
6) Weight is being transferred from one limb to the other.
- Initial Contact (IC)
- Moment when calcaneus (or any part of foot) first hits the ground. It is the 0-2% portion of GC.
- HEEL ROCKER
- Loading response, 0-10%
- IC, shock absorption, heel rocker, getting foot flat on to ground, and transferring weight. Its the time to provide stability while transfering weight.
- When contralateral foot leaves the floor.
- Hip: Flexed (but stable, not moving really)
- Knee: Basically extended (just slightly flexed)
- Ankle: DF (dorsiflexion) in neutral position
- Hip: Flexed (but stable, not moving really)
- Knee: Flexing
- Ankle: PF (plantarflexion)
9) The Rockers
- First is HEEL ROCKER (initial double limb stance). Starts at IC and goes through first part of LR until foot is flat and bearing weight.
- Then once LR is done and foot PF's and is flat on ground, ANKLE ROCKER happens (during single limb stance, specifically the mid-stance)
- Then as heel comes off ground (preparing for swing phase), FOREFOOT ROCKER happens (during terminal stance part of single limb stance phase ... so 2nd half of single limb stance phase)
- Finally at the very end you have a little TOE ROCKER (during pre-swing phase of the terminal double limb stance)
10) It rapidly progresses from the hindfoot to the forefoot
11) Mid Stance (10-30%)
- Terminal Stance (30-50%)
- PUSH OFF (from the forefoot rocker)
12) Terminal stance phase (of the second half of the single limb stance phase)
- You are up on balls of feet / metatarsal heads, so your COM/COG is anterior to the AOR down on forefoot, so you will fall (unless you can get your foot out in front of you to stop the fall).
13) It is in swing phase
- Hip: Extension
- Knee: going into extension
- Ankle: DF at first, but then when pushing off goes to PF
- Preswing (50-60%), when contralateral limb touches and you get up into toe rocker. Ends when toes leave the ground. We are done with push off, now it's just muscles contracting to get foot off the ground.
- 3 (initial, mid, and terminal)
- Initial swing (60-73%), first 1/3 of swing phase, begins when foot leaves the floor and ends when swing foot catches up to the contralateral leg. Purpose is to swing foot forward keeping foot from catching the floor.
- Swing foot catches up with heel of contralateral foot.
- Mid swing (73-87%), 2nd 1/3 of swing phase, begins when swing foot catches up to heel of contralateral foot, and ends when tibia is aligned vertically (which is when hip and knee flexion angles are equal). Purpose is to swing foot forward keeping foot from catching the floor.
- Terminal swing (87-100%), 3rd 1/3 of swing phase, begins when tibia is vertical, and ends foot strikes the floor (completing a gait cycle ... or beginning of double limb stance phase again). Purpose is to finish advancing limb but also prepare slowing down the hip and tibia, aligning joints to bear weight, and get ready for contact of ground.
- Hip: Moving into flexion
- Knee: Flexion (to clear foot from ground)
- Ankle: Slight PF after pushoff then moves into DF
- Hip: Flexion
- Knee: Starting to extend
- Ankle: DF
- Hip: Flexion
- Knee: Extension
- Ankle: DF (neutral)
SO LETS SUMMARIZE AND REVIEW:
1) What is it called when your right foot goes through a stride
- How many MAJOR phases are there in a Right Gait Cycle (name them and the % of time they take up)
2) List each sub phase and the periods of those sub-phases:
3) Below, what phase / subphase and rough % would these happen at:
- Initial contact of R foot
- Opposite (left) toe off
- Heel rise (of R foot)
- Opposite (left) heel contact
- R foot toe off
- Feet adjacent (with R foot in swing phase)
- R tibia vertical
- R foot contact again
1) Right gait cycle
- Stance phase (60%), Swing phase (40%)
- Initial double limb stance (10% of total)
Initial Contact (IC): 0-2% ...... heel rocker
Loading Response (LR): 0-10%
- Single limb stance (40% of total)
Midstance (10-30%) ..... ankle rocker
Terminal Stance (30-50%) .... heel rocker
- Terminal double limb stance (10% of total)
Pre-swing phase as contralateral limb touches (50-
60%) ... toe rocker
- Swing (40% of total)
Initial swing phase (60-73%)
Mid swing phase (73-87%)
Terminal swing phase (87-100%)
- Initial contact (0-2%)
- End of Loading Response of R foot (at 10%)
- Right between mid and terminal stance (30%)
- Beginning of preswing phase (during terminal stance phase) - 50%
- Beginning of swing phase or initial swing phase starts (60%)
- Transition between initial and mid swing phases (73%)
- End of mid swing phase (87%)
- End of terminal swing phase (100%)
Lets review the ROCKERS
1) How many rockers are there?
- What are the rockers?
2) When (what % time period) does heel rocker happen
3) T or F: Ankle rocker = tibial advancement
4) Forefoot rocker starts when
5) When does toe rocker start
- Heel rocker, ankle rocker, forefoot rocker, toe rocker
2) Starts at IC and goes to mid LR (so about 0-5%)
4) When heel comes off the ground (start of terminal stance phase of the single limb stance phase)
5) When the contralateral foot strikes the ground so you can start to shift weight. At the start of preswing phase around 50%
1) What is the locomotor unit, and what is included in it?
- What is the purpose of the locomotor unit
2) What is the passanger unit, and what's included in it?
- T or F: the HAT unit and locomotor unit have shared parts? Explain
3) COM (or COG) for the locomotor unit is where:
- COM for the HAT unit is where:
4) T or F: about 1/2 way through the loading response, the leg touching down will then be bearing 100% of the weight?
5) So if your weight is 1 body unit, how come in the middle of the gait cycle when 100% of the weight is on that stance leg, why does the weight fall below 100% of the body unit? Explain
- So in short, explain the VERTICAL ground reaction force through the gait cycle (related to this point)
5A) Real quick on GRF ... GRF is ground reaction force = normal force. Remember that the GRF is always perpendicular to the surface of the ground. BUT, in class he has the GRF going at an angle based on the angle of the body weight. Why? Explain
6) What would the vertical ground reaction force be during the swing phase
7) Explain the anterior-posterior force of the ground reaction force during gait and what happens:
8) Explain the medial-lateral force of the ground reaction force during gait and what happens:
- When your heel hits the ground, does your foot immediately move into supination or pronation? Why
9) During Sup/Inf GRF, what % of body weight:
- During Ant/Post GRF, what % of body weight:
- During Med/Lateral GRF, what % of body weight:
10) The breaking / propulsion force was what force of the 3 below:
1) LE's, hips, pelvis, and lumbar spine
- Provide movement
2) The HAT unit: head, arms, trunk
- TRUE The lumbar spine, pelvis, and hips are technically shared by both. They are the connection between the 2.
3) Just anterior S2
- Mid-thoracic spine (anterior to vertebral bodies) about T7-T8 in mediastinum
5) Momentum. If you hold a book in your hand and push it up in the air and then back down, it will way more on the way up and less on the way down. So just like that book, as your COM of body is going up and down it weighs more or less.
- It is nothing at first, then when you touch down it begins to climb and peak at 1.0 body unit when you are 100% weight bearing. But it then decreases slightly as momentum of body changes (like book falling down). Then as you do forefoot rocker and push down hard into the ground, it goes ABOVE the 1.0 body weight, and then drops significantly after that.
5A) This is the resultant vector of the 2 orthogonal vectors of the GRF. So the normal force (or GRF) does in fact go perpendicular to the ground, just like a person's gravity only goes down vertically. But both gravity and GRF have orthogonal vectors that produce a resultant vector. So the angled GRF Dr. T draws is in fact the resultant vector of the GRF.
7) When you first heel contact, the GRF (or resultant vector of it) helps you BRAKE or stop, so it is high on the posterior and plantar heel. But as you move through the stance phase and get to the point of push off, now the GRF (resultant vector) is pushing or propelling you forward to help get you going and the force is on anterior part of your plantar foot.
8) Right as you do heel down, the GRF is directed slightly laterally during IC and heel rocker. Then as you go through LR, that GRF starts to shift medially as your foot pronates. The medial force continues during single limb stance, and then starts to go back to the lateral side during terminal stance and terminal double limb stance as you transfer weight.
- Pronation, to start absorbing shock
1) When you first strike the ground with your heel, what major muscles are activated (knowing many are, but what are the major ones) and what are they doing
- Where is the GRF line in relation to the AOR during initial heel contact
- So because of where that GRF is (based on the AOR), what will it do to the foot/ankle?
- Is GRF passing anterior or posterior to the knee at this point? Why?
- So what would GRF do to the knee? Why?
2) Explain what ground reaction force is (normal force)
- So on a flat surface, if your book is placed on a flat surface, which way would the GRF point?
- So on a sloped surface, if you book is placed on that sloped surface, which way would the GRF point?
3) We are now in loading response. What rocker is happening?
- Would GRF be more or less than at IC. Why?
- Is foot on the ground here?
- Where is AOR with regards to the knee (anterior or posterior)?
- Where is AOR with regards to the hip (anterior or posterior)?
- The GRF would thus cause knee flexion or extension? And hip flexion or extension?
- So what main muscles are working to counter act that?
4) Now in mid-stance phase, where is GRF pointing?
- So now where is AOR with regards to the ankle
- What would this GRF do to the knee (knowing it is anterior to the ankle)
5) T or F: we turn the quads on more and more throughout the stance phase of the leg? Why?
6) During terminal stance (2nd 1/2 of stance phase), GRF force will go through knee and hip. We start to bend the knee to prepare to get up on forefoot to push off. What muscle helps bend the knee?
- What else will the gastroc do here?
7) In pre-swing phase, the GRF is going through anterior foot and then posterior to the knee. Would this cause knee to extend or flex?
- But we can't have foot come off the ground yet, so what 2 thing keep forefoot / toes on the ground?
- Are the hamstrings activated during the pre-swing phase? Why?
1) Quads and hamstrings both concentrically contract to stabilize the knee as we contact the ground. AND Dorsiflexors help eccentrically hold the foot up as it descends down.
- GRF is just behind the AOR (malleolus)
- Shove it into PF
- Anterior (GRF is straight up). GRF is straight up at heel contact because there is NO weight/force yet, so GRF is always perpendicular to ground/surface. Once we move into LR though the RESULTANT part of the GRF will change and become angled as we shift weight down to stance leg.
- Push it into extension. Because it pushes foot up, which pushes tibia back, which forces knee extension.
2) The force perpendicular the surface to where the object is pushing down (opposite gravity)
- Perpendicular to surface straight up
- Perpendicular to surface but diagonal / sloped (like the surface)
3) Ankle rocker
- MORE. There is more force now pushing down, thus more GRF pushing back.
- Flexion at both
- Glutes and quads
4) Well at exact mid stance the GRF is straight up, but as you move slightly anterior, the RESULTANT vector of the GRF changes and thus points a bit anterior.
- Force it into extension
5) False. We turn it off. At first it needs to stabilize the knee, but as we do ankle rocker (tibial advancement). we need the knee to flex, so quads have to shut off more. We especially need quads off at first part of swing so knee is flexed to clear the ground.
- Plantar flex (pull heel off)
- Plantar flexion of foot by gastrocs, and rectus femoris pulls tibia forward a bit (starts to activate a bit, and then will activate a lot during swing phase to bring tibia forward).
- Not really. They could help flex the knee a bit, but they obviously extend the hip, and during pre-swing we want hip to start moving into flexion so hamstrings would counter that (and thus need to be turned off).
For the muscles below, explain when they'd be 'on' or activated during the gait cycle:
- Gluteus Max:
- Glut med/min:
- Tibialis Anterior:
- Semitendinosus and Semimembranosus
- Gluteus Max: On heel contact you have it activated to prepare to extend leg. It then turns off (pretty much) and starts to eccentrically contract preparing for heel down again, then concentrically contracts to pull hip into extension after IC and during LR.
- Glut med/min: remember that as you are in single limb stance, your weight would just shift to non weight bearing side, so glute med/min activate during stance phase to help keep contralateral pelvis up. They also activate right before IC to align leg properly (help ab/adduct foot or leg into proper alignment)
- Tibialis Anterior: Right at heel contact it is neutral, then quickly will eccentrically lower foot to the ground while it PF, then the muscle basically turns off, and then it activates at heel coming off to bring foot into dorsiflexion during swing phase.
- Soleus: Active during ankle rocker / tibial advancement to help slow down tibial advancement. Then it helps PF ankle during heel off.
- Semitendinosus and Membranosus: Right as you heel down, you need to stabilize the knee, do a little hip extension but they mainly turn off, then they help eccentrically slow tibia during swing phase to slow it down.
- Quads: At heel contact down it activates to stabilize the knee and help bear weight. Then at swing phase it helps bring tibia forward. Rectus femoris is also specifically active during pre-swing to somewhat prevent too much knee flexion (but vastus lat/med are turned off during pre-swing).
1) Are GRF's happening during swing phase?
2) The movement of the leg during swing phase is a result of 2 main things:
3) What muscles are activated during initial swing phase (of swing phase):
- Why do you only use the biceps femoris short head and not all the hamstrings
4) What muscles are activated during mid swing phase (of swing phase):
- Will quads activate to propel tibia forward
5) What muscles are activated during terminal swing phase (of swing phase):
2) Muscle activation and momentum
3) 1 jt hip flexors, biceps femoris short head to flex knee, and dorsiflexors
- All the hamstrings would extend the hip during initial swing (and that's not the direction we want the hip to go during this phase).
4) 1 jt hip flexors, dorsiflexors
- Not really. This is more momentum. Then when tibia is anterior (at end of mid swing phase) then the quads need to activate a bit to extend the tibia/knee.
5) Quads and hamstrings need to get ready to stabilize the knee to take on force, dorsiflexors keep foot dorsiflexed.
Below are flashcards on the FINAL lecture:
1) What does Temporo-spatial mean
2) For TIME, what roughly is avg speed of walking/gait for normal person
- How many steps (while walking) per min (cadence)
- How many steps (while running) per min
- Velocity =
- Cadence =
3) Now for DISTANCE, what roughly is the step length for avg adult
- Distance for stride length for avg adults
- Distance for stride length for children
- Avg distance between BOS legs
- What is the degrees of toe out (angle from heel to 2nd ray)
1) Time and distance
2) 3.1 mph (3.2 for men, 2.9 for women, about 10% slower for older adults)
- 113 steps/min
- 180 steps/min
- Velocity = step length * cadence
- Cadency = how many steps you take per min
3) 27.76 inches (28 for men, 25 for women)
- 55.51 inches (57 for men, 50 for women)
- 1.36-1.48 x their leg length
- 1-5 inches
- 7 degrees
Looking at the ANGULAR changes at the ankle, knee, and hip during gait
1) Total ROM of the ankle during gait at the ankle is:
- Angle of ankle at initial contact (IC)
- Right as you move into LR and load the foot, what happens to the angle of the ankle
- At mid LR phase as weight is all shifted over, you start to move to ankle rocker, and what happens to the angle of the ankle
- Ankle keeps doing DF until when (what phase)
- T or F: You start doing push off while still moving in slight DF?
- T or F: Right after toes leave the ground, you do a bit of PF
2) How much DF do most people have?
- T or F: we use most of our DF ROM during gait
3) We need more DF or PF ROM during gait?
4) What two phases during gait cycle does RAPID PF happen?
- T or F: after the foot leaves the floor, there is a period of brief PF
5) Angular velocity of these rapid PF periods =
6) Amount of knee flexion ROM you need for normal gait is:
7) T or F: At time of initial contact, our knee is in full extension?
- Does the knee flex or extend during the LR? Why?
8) During most of single limb stance, is the knee flexing or extending?
- So in gait cycle, explain what is happening at the knee
9) We know the knee is flexing in preswing phase and the majority of swing phase ... what degree or amount of flexion ROM does it get up to?
- At the very end (near terminal swing phase) what happens at the knee
10) Does the knee ever go into true extension
- T or F: Terminal swing phase could also be thought of as pre-stance phase?
11) In the ankle we had 2 periods of rapid PF ... what are the periods of rapid movement in the knee?
- What is the angular velocity of these rapid knee movements?
12) When someone has a pathological quick kick into knee extension after touch down, what is happening:
13) A good summary: the hip provides stability, the ankle responds to action at the floor and provides mobility, and the knee just responds to both hip and ankle movements
14) The ankle had 2 rapid phases, the knee had 3 rapid phases, but the hip has how many phases (and any rapid?)
15) When you first hit the ground, what is the hip doing?
16) Total ROM for the hip during a gait cycle is:
17) When does the hip move into extension ... is it during IC, LR, or Stance phase?
18) Hip goes into extension through the later initial double limb stance and single limb stance phases, but when exactly does it move into flexion again?
19) What is the angular velocity of the hip movement
1) 30 degrees
- Increases ... Moves into PF (down to almost 10 degrees of PF). So as you do heel rocker, you move into PF
- Decreases ... Moves into DF
- You go through mid and terminal stance phase, and at the end of terminal stance phase you stop doing DF and start moving into PF at the forefoot rocker and toe rocker.
2) About 10-12 degrees
3) PF (we do about 10-12 degrees of DF, and about 20 degrees of PF, for a total of 30 degrees ROM).
4) Right after heel contact during first part of LR, and then right at the very beginning of swing phase / end of pre-swing phase.
5) 300-400 degrees per second
6) 60 degrees.
7) False. It is just slightly flexed
- Flex. Helps with shock absorption
- It starts in slight flexion, but basically extended. It then moves into flexion during heel rocker and LR to do shock absorption. But then during ankle rocker and tibial advancement, the hip is extending and pushing the knee into an extension motion (more towards extension). Then it rapidly goes into flexion to prepare for push off, pre swing, early swing phase, .... and then goes into extension at terminal stance phase.
9) 60 degrees
- Now it extends to prepare to touch down and do stabilization of the knee and shock absorption.
10) For most people it does NOT, but some get a bit of extension.
11) 2 periods of rapid flexion (one right during LR, and the other starting at pre-swing and early parts of swing phase). AND a phase of rapid extension right as you prepare to get foot on the ground
- 300-350 degrees per second (dps)
12) Could be weak quads, can't control the GRF (which is pushing it into extension).
13) ok (the knee is a 'follower' where the hip is for stability)
14) 1 phase of extension and 1 of flexion ... and both are not very rapid
15) In a lot of flexion, but providing stability
16) 40 degrees (30 in flexion, 10 in extension)
17) Hip moves into extension only when full weight of body is transferred over (so mid LR phase). It provides stability and stays in place until mid LR when weight is totally shifted over.
18) During pre-swing phase (50-60%) is when it starts moving into flexion again.
19) Around 200 dps
Below are the flashcards for the FINAL class
1) With the ANKLE, explain the EXTERNAL torques that happen at the ankle during gait
- How or why does this happen?
- Is the external torque (GRF) providing DF or PF torque at the ankle during preswing toe rocker?
2) When you touch down / heel down (initial contact), what angle roughly is the ankle at
- Where is GRF
- What is External torque, and what is it doing?
- What is Internal torque, and what is it doing?
3) During Loading Response (LR)
- What rocker do we begin now
- Is the foot flat on the ground?
- Where is GRF
- So if GRF is through the AOR, what is the External torque?
- As we go into Ankle Rocker, if GRF momentarily provides no external torque, what is the external torque
- Then what is the internal torque at this moment
4) During Midstance phase
- What rocker is happening
- What is External and internal torques happening during ankle rocker?
- What slows or controls tibial advancement
- If a person can't control or loses function or has a tight soleus, what would happen?
- So in normal gait with everything working normal, will the External torque or internal torque be greater at this moment of ankle rocker? Why?
5) For terminal stance
- What is the main movement that signifies you've moved from mid stance to terminal stance?
- T or F: During single limb stance phase, your foot is flat on the ground during the entirety of this phase? Explain
- Explain what happens with the gastrocs during single limb stance phase
6) Imagine the foot at the end of terminal stance phase, how will it look?
- What is it called as to what is happening in the foot at this point? And why is this important / what does it do and provide for?
7) When you do forefoot rocker, are you doing pronation or supination of the foot? Why?
- As you are doing forefoot rocker, what stance / phase are you in?
- What is external and internal torques here at this point
- Would the internal torques (from last point) be eccentric or concentric at this point? Why?
8) During preswing phase
- What is happening with your weight at this point
- What is happening at the knee at this point
- What is happening at the ankle
- What is the external torque and internal torque here
9) As you go now into swing phase (all three sub phases within it) explain what happens at the ankle
- What is external torque on ankle during swing phase ... but what?
10) During initial swing phase
- Review where this phase starts and ends again
- What muscles work during this period
11) T or F: during mid swing, the tibia primarily moves as a result of momentum
- Review when mid swing phase starts and ends
- Are ankle dorsiflexors still working?
12) For Terminal swing phase
- Review start and end parts of this phase
- T or F: Terminal swing = prestance phase
- At this point, are the dorsiflexors working concentrically, eccentrically, or isometrically
1) At the very first IC and first part of LR, the external torque (GRF) pushes heel up forcing foot into PF. But mid LR as you then weight bear, the external torque (GRF) pushes the entire foot up into DF.
- At heel contact (or initial contact) the GRF is posterior the malleolus, thus forcing the calcaneus up which pushes forefoot down (PF). But as you go into LR, the GRF now moves ANTERIOR the malleolus, thus pushing forefoot UP (thus DF).
- DF (but GRF is significantly decreasing as foot is coming off the ground).
2) Neutral (90 degrees)
- Posterior to malleolus
- GRF, pushing ankle into PF
- Internal torque is what is resisting or countering the external torque. So this would be the dorsiflexors which isometrically resist GRF at heel contact, and then move into an eccentric contraction to lower foot through heel rocker into LR.
- Ankle rocker (tibial progression)
- Through the center of AOR (through malleoli)
- Dorsiflexors concentric contraction
- Eccentric soleus contraction on tibia (an eccentric PF torque)
- Ankle rocker
- External is dorsiflexor muscles, and internal is soleus keeping tibia from advancing too much
- Soleus muscle
- The person would TOE walk
- External torque is greater because ... if the soleus (internal torque) pulled harder than ext. torque of dorsiflexors, it would not let tibia advance.
- The heel comes off the ground
- False. For mid stance (10-30%) the foot is flat on ground, but terminal stance (30-50%) the heel comes off the ground.
- At first the gastrocs don't turn on. Just the soleus contracts eccentrically to stop tibial advancement. But at the end of terminal stance phase when we prepare for swing phase and need to flex the knee, the gastrocs turn on to help flex the knee (and help with PF).
6) Heel completely off the ground and you are up on metatarsal heads doing push off ready for preswing phase.
- Windlass mechanism (toes dorsiflexing pulling plantar aponeurosis tight, causing arch of foot to increase = creating STABILITY so you can distribute weight down to metatarsal heads).
7) Supination. You need to get a more closed packed position as you bear weight going up onto metatarsal heads (forefoot rocker).
- Terminal stance phase
- External is dorsiflexors, and internal is gastroc/soleus
- Concentric (before they were stopping tibial advancement, now they are raising heel so concentric)
- It is transferring to the other limb
- Short head of biceps femoris flexes it
- Slight plantar flexion
- External is still DF, internal is a concentric plantarflexion
9) It slightly PF's as you finish pre-swing, and then it goes into DF all the way through swing phase (to clear foot from the ground). It gets past neutral and then slightly PF to get to neutral before heel contact again.
- NOTHING ... but of course muscles are still working, and you have momentum, and you still have gravity working on the limb.
- Starts as toes come off ground, ends as toes reach contralateral foot's heel
- 1 jt hip flexors to flex hip, short head of biceps femoris to flex knee, and dorsiflexors for ankle.
- From when foot reaches heel of contralateral foot, to when tibia is vertical
- From tibia being vertical to right before heel down / initial contact
1) If you viewed the heel from behind someone as they walked or ran, the GRF would be oriented where (in relation to the achilles tendon)?
- What motion would this cause at the calcaneus/talus
- Is this good or bad
- So right at IC and heel down, are you in inversion or eversion?
- As you weight bear, do you move into inversion or eversion?
- About what point does it start moving back into an inversion motion?
- What helps prevent too much pronation
2) Windlass mechanism would be employed during what phase?
1) Slightly lateral on the heel/calcaneus going up
- Slight eversion (or pronation)
- Good - it is what we want, to go into pronation to help bear weight / loose pack position / shock absorption
- Around 30% .. so starting terminal stance (so end of midstance and heel off) - you start progressing back towards inversion and standing more on the lateral side of the foot.
- Eccentric contractions of tibialis posterior (and spring ligament)
2) Terminal stance phase
1) At the time of Initial contact and heel rocker, would the external torque be pushing the knee into flexion or extension?
- As you then move into ankle rocker, would the external torque be pushing the knee into flexion or extension?
- From end of midstance and all of terminal stance, what is external torque on the knee
- Then preswing phase what is external torque on the knee
- Is there a lot of ext. torque on the knee during gait
- How many flexion and extension torques are there in a gait cycle at the knee
- Is there external torque at the knee during swing phase
- During forefoot rocker, what is ext torque on knee
- During preswing, what is ext torque on knee
2) What is the external force at the knee during initial contact
- What provides the internal torque at the knee during initial contact
3) During loading response, what is muscle activation at the knee
4) Explain how GRF and muscles interact during midstance phase
- T or F: There is not a huge amount of need for muscle contraction late in mid-stance? Why?
5) During preswing phase, what is happening at the knee
- What rocker is during preswing
- GRF is very much so behind the knee now, so it sends knee into extension or flexion
- What muscle eccentrically contracts to control that
- Are we plantar or dorsiflexing at this moment?
6) During initial swing phase
- What is the knee doing
- Is 1 joint or 2 joint hip flexors helping flex hip? Why?
7) T or F: During mid swing, most muscles turn off and momentum carries the motion forward
- We know knee is flexed during mid swing, but is it going into more flexion, maintaining flexion, or decreasing in flexion (slight extension) during mid swing?
- Extension, Flexion, Extension, Flexion (2 of each)
3) Quads and hamstrings both contract to stabilize the knee
4) Early part the GRF falls posterior to knee (forcing flexion) and anterior the hip (forcing flexion), but then late midstance the GRF goes anterior the knee (forcing extension) and about anterior the hip (forcing extension)
- True. GRF helps push both knee and hip joints into extension where they need to be (not much muscle needed).
5) It is rapidly flexion
- Toe rocker
- Rectus Femoris
- Slight PF
- Short head of biceps femoris helps flex knee (so hip doesn't extend by all the hamstrings turning on).
- 1 joint. If 2 joint (rectus femoris) did, it would extend the knee, and we need knee flexed.
- Goes from max flexion to less flexion throughout swing phase
1) How many degrees / planes does the knee have movement in?
- During normal gait, about how many degrees of ROM do we need in these 3 planes?
- From IC down to toe off, does the tibia ER or IR?
- Which way is talus rotating?
2) Looking now from the anterior side, seeing a frontal plane view, what is GRF as you touch down
- Would this create a valgus or varus torque at the knee
- What is the internal torque that resists this varus torque
- T or F: Most normal knees have the physiologic valgus of 5 degrees, but as they step down, the GRF forces the knee into a slight varus movement?
- As you experience this varus force, does it shove the knee into varus?
- T or F: As you push off and go into swing phase, the knee naturally goes back to its resting slight valgus position
3) For varus and valgus motion, is the femur or tibia the part that moves?
1) 3: Sagittal (flexion/extension), slight frontal of ab/adduction, and slight transverse of rotation.
- Flex/Ext: 60 degrees
- Ab/Add: 8 degrees
- Rotation: 8 degrees
- Medial rotation
- Medial and down
2) It comes up through ankle and tibia but comes MEDIAL to the knee.
- Lateral collateral lig of the knee (fibular), AND the medial femoral condyle hitting the top of medial tibial plateau (bony apposition) and creating the resistance internal torque
- No, just more varus than the neutral normal physiologic valgus position (but it never goes into full varus no).
1) Explain the external torques around the hip throughout the stance phase
- Where does extension torque peak
- Why does it decrease there?
2) Right at initial contact, the GRF forces hip into flexion, so what m's do we need to counter that
- Are hamstrings helping to extend hip at time of IC
3) As we move into LR and do more weight bearing, what is happening at the hip
- So are hip m's firing during LR and into midstance?
4) What limits too much hip extension
5) Hip flexion begins when?
6) T or F: iliopsoas contracts throughout the entire swing phase
7) At the end of terminal swing phase, what are the hamstrings doing?
8) We know the Glut med/min activate to stabilize the hip (prevent contralateral side in swing phase from falling), but do they work/activate any other time?
1) At initial contact, GRF is anterior hip joint AOR, so it forces it into flexion, but that quickly changes as you load and put weight on foot during LR. Then during the single limb stance phase it progressively moves to more and more extension torque
- End of terminal stance
- We get less and less GRF as we do toe rocker and take foot off ground.
2) 1 jt hip extensors (glutes)
- No they are stabilizing the knee.
3) Mainly providing stabilization.
- Not a lot no. Just stabilizing
4) Hip jt lig's (3 total), the TFL and 1 jt hip flexors go on stretch or work eccentrically.
5) When the contralateral foot hits the ground (pre swing phase)
6) False. Initially it is active and strongly contracts, but near mid swing it turns off (momentum takes over).
7) Helping to eccentrically de-accelerate the femur and tibia, and getting ready to concentrically contract to stabilize the knee in preparation for loading the knee at IC.
8) At the point where you are about to touch down again (after swing phase) the glut med/min will activate or turn off in order to position the leg on the ground where it is needed from a frontal plane standpoint.
Think of all the phases throughout the gait cycle, and what two phases do most falls happen at?
T or F: Gait is sometimes referred to as a 'controlled fall'
- Initial contact (lose footing, etc.)
- Preswing transition to initial swing ... when you don't set up that transition right (don't dorsiflex enough, don't flex knee enough).